In response to the letter published on your website on 3rd October, I thought it necessary to clarify some important issues with your readers.

The local NHS is committed to ensuring that issues around risk in childbirth are communicated clearly and mums to be have the best and latest information available when making important decisions and choices for themselves about where to give birth. It’s important to recognise that the evidence base relating to childbirth evolves and matures over time as more robust studies are completed.

In many cases this evidence supersedes previous recommendations, assertions and opinions.

The Birthplace in England study is the largest study of its kind to date, using a cohort of 64,000 low risk births in England and Wales. Over 97% of NHS Trusts providing home birth services and 90% of all midwifery units in England and Wales took part. A subsequent Cochrane Review of Midwife Led care published in 2013 has supported the findings of the Birthplace in England Study that outcomes are better for low risk women in midwife led models of care.

Turning to the specific comments made in the letter: "It is true that the study found advantages in these settings for women who had already had a baby but you will see there are risks for first time mothers."

Risk is an inherent part of life and everyone in local NHS services and BSBV are committed to reducing risk as much as possible. There are risks for women giving birth in hospitals as well as at home and this has not changed over past years.

The proposals for change in maternity services made by the local clinicians advising BSBV are aimed at reducing risk for all women. The Birthplace in England study looked at the safety of birth for the baby and the mother where the woman’s overall risk was considered to be low.

The following conclusions were reached with regard to risk:

1. "For planned births in freestanding midwifery units and alongside midwifery units there were no significant differences in adverse perinatal outcomes compared with planned birth in an obstetric unit."

2. "Women who planned birth in a midwifery unit (AMU or FMU) had significantly fewer interventions, including substantially fewer intrapartum caesarean sections and more ‘normal births’ than women who planned birth in an obstetric unit."

3. "For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother."

4. "For women having a first baby, a planned home birth increases the risk for the baby"

The only increase in risk was related to the babies of women have a first baby at home. The difference was 9.3 adverse outcomes per 1000 births, as opposed to 5.3 per 1000 in hospital. This is why it is so important to have a full and frank discussion between women and midwives or obstetricians, so a woman considering a home birth is able to make a personal choice that is based on up to date evidence of what her chance of something going wrong might be.

We must not forget that a similar discussion must happen for those women with underlying medical conditions or pregnancy problems who would be advised that hospital birth with full consultant obstetric support throughout 24 hours every day is considered safest for them. "For women having a first baby, there is a fairly high probability of transferring to an obstetric unit during labour or immediately after the birth."

It is true that transfers for first time mums from midwifery led units are higher than for mums who have already had a baby. However, there is no evidence to suggest that this puts either them or their baby at additional risk when compared to giving birth in hospital. There is data emerging from established stand alone midwifery units that the transfer rates for women having first babies do decrease as the midwives working in this model of care gain confidence and experience. As a result fewer women using these centres are asking for epidural analgesia, the most common reason for transfer to an acute unit.

The letter also cites Royal College of Obstetricians and Gynaecologists (RCOG) guidance from a Darzi report of 2008, which the RCOG have confirmed to me is not their current guidance. They have confirmed in writing that they make no recommendation about safe transfer times for women and there is no evidence for such guidance. This letter is available on the BSBV website. 

Maternal choice of where to give birth is hugely important and we would encourage mums to be reading this letter to discuss options with their midwife, GP or obstetrician so they can make an informed decision about their future place for birth. Finally, as a point of accuracy, the letter cited was not from ‘BSBV staff’, it came from obstetricians from Kingston and Epsom and a GP from Wandsworth who have been advising the programme.

Christina McKenzie, Midwifery consultant MHM, RM, ADM, PGCEA

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